Safety Stimulation
Xorian
14 days ago
24
files (4)Instructions-SafetyPlanStimulationAssignment.docx
SOAPNoteTemplate.docx
patientschart.pdf
- Patientsvideo.mp4
Instructions-SafetyPlanStimulationAssignment.docx
Safety Plan Stimulation Assignment
Instructions/Scenario
1. A patient was seen by a Nurse Practioner in a health setting and has made a referral to social work (you).
2. Review the patient chart prior to your visit with the patient (video of the patient session).
3. Identify any risk factors from the patient chart/video.
4. Then, identify safety strategies that could address each risk factor highlighted in the patient chart/video.
5. Complete a SOAP (Subjective, Objective, Assessment, Plan) note (Using this SOAP note template). (I’ve attached the SOAP Template as another attachment)
6. Upload completed SOAP note in response to this assignment.
To begin the simulation please view the patient chart and the patient visit video:
Patient Chart is attached as another PDF. Patient’s video is also attached.
(Prof’s notes - What I will be looking for in your SOAP note is to gather as much information and detail as possible and put it in one place, then from that information assess and identify risk factors and plan safety strategies according to and to address those risk factors.
The sections in your SOAP note should not be brief, you should be inputting information from all sources provided to ensure you are assessing all the details available. No section should be only a few sentences or bullet points. Your plan section should not be “to develop a safety plan”. I want to see the details of that plan written out along with any other aspects of the plan you have come up with. )
Please see the rubric Below:
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SOAPNoteTemplate.docx
Domestic Violence Safety Planning Simulation
Social Work SOAP Note Template
Patient Name:
DOB:
Age:
Social Worker (Social Worker Name):
Referred by (Nurse Name):
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S: Subjective Subjective data includes clinically important statements made by the client in the video (feelings, thoughts, actions, goals, concerns). You may quote directly or summarize the client statements. This section does not assess or interpret those statements. |
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O: Objective Objective data includes observations that are measurable or observable without interpretation (patient body language in the video) as well as relevant results from reports and documents (nursing referral information, patient chart information) |
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A: Assessment Assessment section includes the Social Worker’s understandings or hypothesis based on the S and O data. Include all domestic violence indicators and risk factors identified by both Nurse and Social Worker. |
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patientschart.pdf
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Patient Chart for IPE
Name: R.J.
DOB: 1-30-2002
Age: (19 years old)
Vital signs: BP 130/84 Temp: 98.8® F
Pulse 84 min Resp: 22/ min
Height: 5’2” Weight: 120 BMI- 21.9
Occupation: Homemaker
CC: Here for well woman exam, anxiety
History of Present Illness (HPI) (8 Points)
1. Onset: Sudden onset 2-3 weeks ago
2. Setting: At home
3. Location: mind- anxious, nervous, heart racing
4. Quality: “can’t keep my thoughts straight, feels anxious”
5. Quantity: 7 on 0-10 scale
6. Aggravating: I am worried and that’s when I get even more anxious
7. Alleviating: nothing is helping
8. Associated symptoms: worry and headache “don’t want to trouble my boyfriend”
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Current Health Data (CHD) (7 Points)
1. Meds: took Tylenol for headache 500 mg 2 tablets last night
2. Allergies: “strawberries make me break out”, NKDA but denies environmental allergies
3. LMP: 13 weeks ago
4. Contraceptive method: “My boyfriend does not want me to use anything but I don’t want
to get pregnant”
5. G T P A L C: Nullipara
6. Immunizations: Current including Influenza 9-1-2020
7. Last PE/Screening: 9-1-2020 (CBC, CMP and Thyroid panel within range)
Childhood illnesses: Name, Age and Date (9 Points)
1. Measles- Denies
2. Mumps- Denies
3. Rubella, - Denies
4. Pertussis- Denies
5. Chickenpox- Denies
6. Rheumatic fever- Denies
7. Diphtheria- Denies
8. Polio- Denies
9. Asthma at age 4 and thru teen years but not as an adult
Adult illnesses: Name, Age and Date (9 Points)
1. Cancer- Denies
2. CAD- Denies
3. HTN- “only when I get stressed my blood pressure gets high”
4. Thyroid- Denies
5. Diabetes- Denies
6. STIs- Denies
7. TB- Denies
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8. Hepatitis- Denies
9. COPD- Denies
Immunizations: Names, Dates and as appropriate for patient by gender and age (14 Points)
1. MMR 2006
2. Tetanus 2016
3. Pertussis 2006
4. Polio 2006
5. Hepatitis A unsure
6. Hepatitis B 2003
7. Influenza 9-1-2020
8. Pneumonia never
9. Varicella 2006
10. Zoster never
11. Meningococcal 2017
12. TB skin test 2015
13. HPV 2014 Past Medical History (PMH) (8 Points)
1. General/Mental/Emotional: “difficulty falling asleep or eating right when I am stressed”
2. Childhood illnesses: asthma at age 4
3. Adult illnesses: “high blood pressure when I am stressed”
4. Hospitalizations: “been to ER last month- fell and hurt my arm and again last year fell-
clumsy and sprained my ankle”
5. Surgeries: “Tonsils removed when I was 6”
6. Trauma/injuries: None- other than the 2 falls in the past 2 months- It was my fault- I am
clumsy”
7. Disabilities: Denies
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8. Transfusions: Denies
Personal/Social History (SH) (8 Points)
1. Smoking: Denies
2. ETOH: Denies
3. Illicit drugs: Denies
4. Occupation: “homemaker now- worked at insurance office before I met my boyfriend,
but my boyfriend does not want me to work”
5. Exposure: Denies
6. Hobbies & Recreational: “take care of the house and cook for my boyfriend”
7. Living conditions: live in an apartment we rent
8. Military: Denies
Review of Systems (ROS) (15 Points)
1. General constitutional: loss of appetite on and off for 1-2 months, stress and headache on
and off for 2 months, and difficulty falling asleep for 1-2 months +
2. Skin, hair, and nails: List 3 easily bruising when bumping into things at the house
3. Head and neck: stress headaches and stiff neck muscles on and off for 1-2 months
4. Eyes: Denies
5. Ear: Denies
6. Nose: Denies
7. Throat and mouth: Denies
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8. Lymphatic: Denies
9. Chest and lungs: sometimes I cant breathe when I am too stressed
10. Heart and blood vessels: BP goes up and heart races when I am too stressed and worried
11. Peripheral vasculature: Denies
12. Gastrointestinal: stomachache for 3-5 days on and off from stress and worry
13. Genitourinary: Denies
14. Musculoskeletal: Denies
15. Neurologic: Denies
OBJECTIVE:
Poor eye contact
Frowning
Shaking her right knee when sitting in the waiting room
Physical Exam
■ HEENT: PERRLA; extraocular movements intact; fundoscopic exam within normal limits: no vessel changes. Tympanic membranes clear bilaterally. Pharynx without erythema or postnasal drip
■ Neck/lymph: Full ROM of cervical spine without pain. No lymphadenopathy noted. Trachea midline; thyroid moves with swallowing, nontender and no enlargement or masses noted.
■ Lungs: Lungs clear to auscultation bilaterally. No masses or tenderness on palpitation of the chest.
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■ Cardio: S1/S2 regular rate and rhythm. No murmurs noted. No S3 or S4; no lower extremity edema; pedal pulses normal
■ Abdomen: nontender, no masses noted on palpation. No hepatosplenomegaly
■ MSK: Full ROM in all joints; muscle strength normal
■ Neuro: Cranial Nerves II-XII intact; Gait normal, DTRs: achilles, patellar, biceps, triceps, radial are 2+ bilaterally
■ Skin: Bruised in varying stages noted on both forearms and lower legs (yellow to purple to pink
■ Pelvic Exam: unremarkable other than cervix has bluish tint and uterus slightly enlarged and globular
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DANGER ASSESSMENT
Jacquelyn C. Campbell, PhD, RN Copyright 2003; update 2019; www.dangerassessment.com
Several risk factors have been associated with increased risk of homicides (murders) of women and men in violent relationships. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of abuse and for you to see how many of the risk factors apply to your situation.
Using the calendar, please mark the approximate dates during the past year when you were abused by your partner or ex partner. Write on that date how bad the incident was according to the following scale:
1. Slapping, pushing; no injuries and/or lasting pain
2. Punching, kicking; bruises, cuts, and/or continuing pain
3. "Beating up"; severe contusions, burns, broken bones
4. Threat to use weapon; head injury, internal injury, permanent injury, miscarriage, choking
5. Use of weapon; wounds from weapon
(If any of the descriptions for the higher number apply, use the higher number.)
Mark Yes or No for each of the following.
("He" refers to your husband, partner, ex-husband, ex-partner, or whoever is currently physically hurting you.)
1. Yes Has the physical violence increased in severity or frequency over the past year?
2. No Does he own a gun?
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3. No Have you left him after living together during the past year?
If you have never lived with him, check here.
4. No Is he unemployed?
5. No Has he ever used a weapon against you or threatened you with a lethal weapon?
If yes, was the weapon a gun?
6. Yes Does he threaten to kill you?
7. Yes Has he avoided being arrested for domestic violence?
8. No Do you have a child that is not his?
9. Yes Has he ever forced you to have sex when you did not wish to do so?
10. Yes Does he ever try to choke/strangle you or cut off your breathing?
10a. (If yes) has he done it more than once, or did it make you pass out or black out or make you dizzy?
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11. No Does he use illegal drugs? By drugs, I mean "uppers" or amphetamines, Meth, speed, angel dust, cocaine, "crack", street drugs or mixtures.
12. No Is he an alcoholic or problem drinker?
13. Yes Does he control most or all of your daily activities? (For instance: does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car?
If he tries, but you do not let him, check here.
14. Yes Is he violently and constantly jealous of you?
For instance, does he say "If I can't have you, no one can."
15. No Have you ever been beaten by him while you were pregnant?
If you have never been pregnant by him, check here.
16. No Has he ever threatened or tried to commit suicide?
17. No Does he threaten to harm your children?
18. No Do you believe he is capable of killing you?
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19. No Does he follow or spy on you, leave threatening notes or messages, destroy your property, or call you when you don’t want him to?
20. Yes Have you ever threatened or tried to commit suicide?
Total "Yes" Answers: 8
Thank you. Please talk to your nurse, advocate or counselor about what the Danger Assessment means in terms of your situation.
Extreme Danger 18 and over Severe Danger 14 - 17
Your Score
14 Increased Danger 8 - 13 Variable Danger Less than 8
Calculate
Reset
Assessment:
Intimate Partner Violence
Plan:
1.Ensure patient safety.
2. Community resources and helpline information given.
3. Referral made to Social Work.
4. Referral to CPS/APS as needed.
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- Extreme Danger
- Severe Danger
- Increased Danger
- Variable Danger
Instructions-SafetyPlanStimulationAssignment.docx
Safety Plan Stimulation Assignment
Instructions/Scenario
1. A patient was seen by a Nurse Practioner in a health setting and has made a referral to social work (you).
2. Review the patient chart prior to your visit with the patient (video of the patient session).
3. Identify any risk factors from the patient chart/video.
4. Then, identify safety strategies that could address each risk factor highlighted in the patient chart/video.
5. Complete a SOAP (Subjective, Objective, Assessment, Plan) note (Using this SOAP note template). (I’ve attached the SOAP Template as another attachment)
6. Upload completed SOAP note in response to this assignment.
To begin the simulation please view the patient chart and the patient visit video:
Patient Chart is attached as another PDF. Patient’s video is also attached.
(Prof’s notes - What I will be looking for in your SOAP note is to gather as much information and detail as possible and put it in one place, then from that information assess and identify risk factors and plan safety strategies according to and to address those risk factors.
The sections in your SOAP note should not be brief, you should be inputting information from all sources provided to ensure you are assessing all the details available. No section should be only a few sentences or bullet points. Your plan section should not be “to develop a safety plan”. I want to see the details of that plan written out along with any other aspects of the plan you have come up with. )
Please see the rubric Below:
